Artificial sphincter insertion

Definition

Artificial sphincter insertion surgery is the implantation of an
artificial valve in the genitourinary tract or in the anal canal to
restore continence and psychological well being to individuals with
urinary or anal sphincter insufficiency that leads to severe urinary or
fecal incontinence.

Purpose

This procedure is useful for adults and children who have severe
incontinence due to lack of muscle contraction by either the urethral
sphincter or the bowel sphincter. The primary work of the lower urinary
tract and the colon is the storage of urine and waste, respectively, until
such time as the expulsion of urine or feces is appropriate. These holding
and expelling functions in each system require a delicate balance of
tension and relaxation of muscles, especially those related to conscious
control of the act of urination or defecation through the valve-like
sphincter in each system. Both types of incontinence have mechanical
causes related to reservoir adequacy and sphincter, or
"gatekeeper" control, as well as mixed etiologies in the
chemistry, neurology, and psychology of human makeup. The simplest bases
of incontinence lie in the mechanical components of reservoir mobility and
sphincter muscle tone. These two factors receive the most surgical
attention for both urinary and fecal incontinence.

Urinary sphincter surgery

There are four sources of urinary incontinence related primarily to issues
of tone in pelvic, urethral, and sphincter muscles. Most urinary
incontinence is caused by leakage when stress is applied to the abdominal
muscles by coughing, sneezing, or exercising. Stress incontinence results
from reduced sphincter adequacy in the ability to keep the bladder closed
during movement. Stress incontinence can also be related to the mobility
of the urethra and whether this reservoir for urine tilts, causing
spilling of urine. The urethral cause of stress incontinence is treated
with other surgical procedures. A second form of incontinence is urge
incontinence. It relates to sphincter overactivity, or sphincter
hyperflexia, in which the sphincter contracts uncontrollably, causing the
patient to urinate, often many times a day. Finally, there is urinary
incontinence due to an inadequately small urethra that causes urine
overflow. This is known as overflow incontinence and can often be treated
with augmentation to the urethra to increase its size.

Only severe stress incontinence related to sphincter adequacy can benefit
from the artificial urinary sphincter.

Normally, the anal sphincter muscles maintain fecal continence (A).
In cases of incontinence, an artificial sphincter may be inserted,
which can open and close to mimic the function of the natural
sphincter (B). Once implanted, the patient uses a pump under the
skin to inflate and deflate the anal cuff (C).
(

Illustration by GGS Inc.

)

This includes conditions that result in the removal of the sphincter.
Sphincter deficiency can result directly from pelvic fracture; urethral
reconstruction; prostate surgeries; spinal cord injury; neurogenic bladder
conditions that include sphincter dysfunction; and some congential
conditions. Each can warrant consideration for a sphincter implant.

Implantation surgery related to urinary sphincter incompetence is also
called artificial sphincter insertion or inflatable sphincter insertion.
The artificial urinary sphincter (AUS) is a small device placed under the
skin that keeps pressure on the urethra until there is a decision to
urinate, at which point a pump allows the urethra to open and urination
commences. Since the 1990s, advances in prostate cancer diagnosis and
surgery have resulted in radical prostatectomies being performed, with
urinary incontinence rates ranging from 3–60%. The AUS has become a
reliable treatment for this main source of urinary incontinence in men.
Women with intrinsic sphincter deficiency, or weakened muscles of the
sphincter, also benefit from the AUS. However, the use of AUS with women
has declined with advances in the use of the sub-urethral sling due to its
useful "hammock" effect on the sphincter and its high rates
of continence success. Women with neurologenic incontinence can benefit
from the AUS.

Artificial anal sphincter surgery

Fecal incontinence is the inability to control bowel function. The
condition can be the result of a difficult childbirth, colorectal disease
such as Crohn's disease, accidents involving neurological injuries,
surgical resection for localized cancer, or by other neurological
disorders. Severe fecal incontinence may, depending upon the underlying
disease, require surgical intervention that can include repair of the anal
sphincter,
colostomy
, or replacement of the anal sphincter. Artificial anal sphincter is a
very easy-to-use device implanted under the skin that mimics the function
of the anal sphincter.

Demographics

Artificial urinary sphincter surgery

According to the Agency for Health Care Policy and Research, urinary
incontinence affects approximately 13 million adults. Men have
incontinence rates that are much lower than women, with a range of
1.5–5%, compared to women over 65 with rates of almost 50%. In
older men, prostate problems and their treatments are the most common
sources of incontinence. Incontinence is a complication in nearly all male
patients for the first three to six months after radical prostatectomy. A
year after the procedure, most men regain continence. Stress incontinence
occurs in 1–5% of men after the standard treatment for severe
benign prostatic hyperplasia.

Artificial anal sphincter surgery

According to the National Institute of Diabetes & Digestive
& Kidney Diseases (NIDDK), more than 6.5 million Americans have
fecal incontinence. Fecal incontinence affects people of all ages. It is
estimated that over 2% of the population is affected by fecal
incontinence. Many cases are never reported. Community-based studies
reveal that 30% of patients are over the age of 65, and 63% are female.
According to one study published in the
American Journal of Gasteronology,
only 34% of incontinent patients have ever mentioned their problem to a
physician, even though 23% wear absorbent pads, 12% are on medications,
and 11% lead lives restricted by their incontinence. Women are more than
five times as likely as men to have fecal incontinence, primarily due to
obstetric injury, especially with forceps delivery and anal sphincter
laceration. Fecal incontinence is frequent in men who have total and
subtotal prostatectomies. Fecal incontinence is not a part of aging, even
though it affects people over 65 in higher numbers than other populations.

Description

Artificial urinary sphincter surgery

The artificial urinary sphincter is an implantable device that has three
components:

an inflatable cuff

a fluid reservoir (balloon)

a semiautomatic pump that connects the cuff and balloon

Open surgery is the major form of surgery for the implant. Infections are
minimized by sterilization of the urine preoperatively and preoperative
bowel preparation. The pelvic space is entered from the abdomen or from
the vagina, with general anesthesia for the patient. Broad-spectrum
antibiotics
are given intravenously and at the site of small incisions for the
device. A urinary catheter is put into place. The cuff is implanted around
the bladder neck and secured and passed through the rectus muscle and
anterior fascia to be connected later to the pump. A space is fashioned to
hold the balloon in the pubic region, and a pump is placed in a pouch
below the abdomen. The artificial urinary sphincter is activated only
after six to eight weeks to allow healing from the surgery. The patient is
trained in the use of the device by understanding that the cuff remains
inflated in its "resting state," and keeps the urethra
closed by pressure, allowing continence. Upon the decision to urinate, the
patient temporarily deflates the cuff by pressing the pump. The urethra
opens and the bladder empties. The cuff closes automatically.

Artificial anal sphincter surgery

The artificial anal sphincter is an implantable device that has three
components:

an inflatable cuff

a fluid reservoir (balloon)

a semiautomatic pump that connects the cuff and balloon

In open abdominal surgery, the implant device is placed beneath the skin
through small incisions within the pelvic space. One incision is placed
between the anus and the vagina or scrotum, and the inflatable cuff is put
around the neck of the anal sphincter. A second incision at the lower end
of the abdomen is used to make a space behind the pubic bone for placement
of the balloon. The pump is placed in a small pocket beneath the labia or
scrotum, using two incisions. The artificial anal sphincter is activated
only after six to eight weeks to allow healing from the surgery. The
patient is trained in the use of the device by understanding that the anal
cuff remains inflated in its "resting state," and keeps the
anal canal closed by pressure, allowing continence. Upon the decision to
have a bowel movement, the patient temporarily deflates the cuff by
pressing the pump and fecal matter is released. The balloon re-inflates
after the movement.

Diagnosis/Preparation

Artificial urinary sphincter surgery

Patients must be chosen carefully, exhibit isolated sphincter deficiency,
and be motivated and able to work with the device and its exigencies. To
characterize the condition to be treated and to determine outcomes, full
clinical, urodynamic, and radiographic evaluations are necessary. The
ability to distinguish mobility of the urethra as the cause of
incontinence from sphincter insufficiency is difficult, but very important
in the decision for
surgery. A combination of pelvic examination for urethral hypermobility
and a leak-point pressure as measured by coughing or other abdominal
straining has been shown to be very effective in identifying the patient
who needs the surgical implant. Visual examination of the bladder with a
cystoscope is very important in the preoperative evaluation for placement
of the sphincter. Urethral and bladder conditions found by the examination
should be addressed before implantation. Previous reconstruction or repair
of the urethra may prevent implantation of the cuff. In open abdominal
surgery, the implant surgery uses preventive infection measures that are
very important, including sterilization of the urine preoperatively with
antibiotics, the cleansing of the intestines from fecal matter and
secretions through
laxatives
immediately prior to surgery, and antibiotic treatment and vigorous
irrigation of the wound sites.

Artificial anal sphincter surgery

Since only a limited number of patients with fecal incontinence would
benefit from an artificial sphincter, it is very important that a thorough
examination be performed to distinguish the causes of the incontinence. A
medical history and physical, as well as documented entries or an
incontinence diary are crucial to the diagnosis of fecal incontinence. The
physical exam usually includes a visual inspection of the anus and the
area lying between the anus and genitals for hemorrhoids, infections, and
other conditions. The strength of the sphincter is tested by the doctor
probing with a finger to test muscle strength.

Medical tests usually include:

Anorectal manometry. This is a long tube with a balloon on the end that
is inserted in the anus and rectum to measure the tightness of the anal
sphincter and the ability to respond to nerve firings.

Anorectal ultrasonography. This test also includes an insertion of a
small instrument into the anus with a video screen that produces sound
waves, picturing the rectum and anus.

X rays. A substance called barium is used to make the rectum walls
visible to x ray. This liquid is swallowed by the patient before the
test.

Anal electromyography. This test uses the insertion of tiny needle
electrodes into muscles around the anus and tests for nerve damage.

Aftercare

Artificial urinary sphincter surgery

Surgery requires a few days of hospitalization. Oral and intravenous pain
medications are administered, along with postoperative antibiotics. A
general diet is available, usually on the evening of surgery. When the
patient is able to walk, the urethral catheter is removed. Patients are
discharged on the second day postoperatively, unless they have had other
procedures and need extra recovery time. Patients may not lift heavy
objects or engage in strenuous activity for approximately six weeks. After
six to eight weeks, the patient returns to the physician for training in
the use of the implant device.

Artificial anal sphincter surgery

Surgery hospitalization requires a few days with dietary restrictions and
anti-diarrheal medicine to bind the bowels. Antibiotics are administered
to lower the risk of infection, and skin incisions are cleaned frequently.
Patients may not lift heavy objects or engage in strenuous activity for
approximately six weeks. After the body has had time to heal over six to
eight weeks, the patient returns to the physician for training in the use
of the pump. Two or three sessions are required and after the training,
the patient is encouraged to lead as normal a life as possible.

Normal results

Artificial urinary sphincter surgery

One problem with the urinary sphincter implant is failure. If the device
fails, or the cuff erodes, the surgery must be repeated. In a study
published in 2001, 37% of women had the implant after an average of seven
years, but 70% had the original or a replacement and 82% were continent.
Studies on men report similar findings. Malfunction has improved with
advances in using a narrower cuff. In one large study encompassing one
surgeon over 11 years, the re-operative rate of AUS related to malfunction
in men was 21%. Over 90% of patients were alive with a properly
functioning device.

Another problem with the surgery is urinary voiding. This may be difficult
initially due to postoperative
edema caused by bruising of the tissue. In the majority of cases,
urination occurs after swelling has receded.

AUS is a good alternative for children. The results of AUS in children
range from 62–90%, with similar rates for both girls and boys.

Artificial anal sphincter surgery

Anal sphincter implant surgery has been successfully performed for many
years. The device most often used has a cumulative failure rate of 5% over
2.5 years. The long-term functional outcome of artificial anal sphincter
implantation for severe fecal incontinence has not been determined.
However, adequate sphincter function is recovered in most cases, and the
removal rate of the device is low. Most of the good results are dependent
upon careful patient selection and appropriate surgical and operative
management with a highly experienced
surgical team
.

Morbidity and mortality rates

Artificial urinary sphincter surgery

Infection has been a frequent and serious complication of surgery, not
only because of the infection per se, but also because infection can cause
erosion of the urethra or bladder neck under the implant. The infection
may actually worsen the incontinence. The overall infection rate with AUS
implants is 1–3%. Because of interactions between the host and the
foreign body represented by the implant, infections can occur soon after
the surgery, or months and even years later. New techniques using
antibiotics and skin preparations have improved infection rates
considerably.

Artificial anal sphincter surgery

This surgery is for a limited number of patients who have isolated
sphincter deficiency. Patients must be chosen who have little co-morbidity
(serious illnesses) and can be trained in the use of the pump. Although it
is a fairly simple operation, some researchers report a 30% infection
rate.

Alternatives

Artificial urinary sphincter surgery

Milder forms of urinary incompetence can be treated with changes in diet,
evaluation of medications, and the use of antidepressants and estrogen
replacement, as well as bladder training and pelvic muscle strengthening.
However, sphincter deficiency, unlike incontinence caused by urethral
mobility, requires a substitute for the sphincter contraction by implant
or by auxiliary tissue. If AUS cannot treat sphincter deficiency, the
sling or "hammock" procedure is a good second choice. It
brings tightness to the sphincter by using tissue under the urethra to
increase contractual function. The
sling procedure
is already preferred over the AUS for women.

Artificial anal sphincter surgery

Milder forms of fecal incontinence are being treated by changes in diet
and the use of certain bowel-binding medications. For some forms of mild
fecal incontinence, special forms of
exercise
can help to strengthen and tone the pelvic floor muscles, along with
providing biofeedback to train the muscles to work with an appropriate
schedule. Only after these measures have been tried, including the use of
pads, is the patient counseled on the benefits of an anal sphincter
implant.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Implantation surgery is performed in a hospital
operating room
by urologic surgeons specially trained for implantation of the artificial
sphincter in the urinary or anal tracts. Successful surgery depends upon
very experienced surgeons.

Tuesday I was supposed to have a TOT (transobturator tape) procedure but this could not be done because I've been radiated. The doctor (who is a reconstruction urologist) mentioned artificial sphincter but wasn't sure if the urethra would hold. What are your thoughts? I go through about 10 diapers a day. I am 62 years post bilateral salpingo oophorectomy.

I have had Crohns disease in my sigmoid colon into the rectum and anus since 1992. In Feb 2009 I was given a colostomy bag and Crohns free now from the offensive organs . But, I am searching for a option to fix spending the rest of my life using a colostomy bag. I would need an anus, rectum type transplant. I am only 39 years old, male. MY past procedure was done at Mount Sani. Feb 2009. All laprascopicly. MY GI Doc is Doc D. Present.

I am hopeful that a lower end GI transplant will put my life back in order, or some other type of device.. I have the means necessary to pay out of pocket if my issuance feels I don't need the procedure. Doc Presents office notified me that there are many studies being conducted. I have no other bowel issues. It was contained only in the very end of my large bowel. Top end of the rectum , sigmoid, and anus. I have all my intestine and it is in very good health. I have been part of the CCFA for years now. I am friends with Doc Sacker, Doc Bayles at John Hopkins, and part of Doc Presents office since 1993. Doc Janowiz I befriended before his death.

I am honestly in need of help and do not wont to spend the rest of my life using a Colostomy bag. I feel a transplantation may be the answer. Please inform me if you have any information on this matter. Other programs being offered. There must be some type of study going on some place.

I've had radical prostate surgery over a year ago and a penis implant after-- My problem is that urine leaks during sexual contact. Is AUS the only alternative to treat this ?--My doctors don't seem to think it's a problem but my partner and I sure do---Is there a specialist in my area who does this on a regular basis?

I had a rectocele.hemorrhoidectomy,and sphincter surgery on Dec.17.On the sphincter surgery, it was stitched up to be alot smaller. I still have diarrhea, which is 5 weeks later. How long does this last and how long do I have to stay on this low residue diet? How long do you wait before having sexual relations? This is the most painful,awful surgery I have ever had.I take an antibiotic(metronidazol 500mg)3 times a day and nexium 40mg daily and drink questran 4gm powder.Dr changed my antibiotic from augmentin 875mg 2 times daily to metronidazol because of the diarrhea.I would just like some answers to see if I am doing the right thing? Thank you so much!!

I need help i have fecal incontince, im 48 years old and had a artifical anal sphincter in for about a year then my dr. said my body started to reject it and removed it i live in fear of having accidents and i have them any given time he told me there was nothing more could be done except wearing a bag which i wont do i wore one to allow time to heal then removed it i had a very hard time having my it adhere to my stomach is there something new that could help me i am very desperate for some help looking forward to your response

My husband had an artificial sphincter implanted to correct stress incontinence caused by treatment by HIFU for prostate cancer. This sphincter was activated 4 weeks ago. My husband complains of constant urinary urgency. This results in frequent visits to the toilet, also at night where he often has to get to the bathroom about 4 times. He has checked for infection the result of which was negative.

Is this urgency due to bruising of the tissue? Will it quieten down after about 3-6 months?

In June 09, I had surgery for colorectal cancer, and it resulted in a permanent colostomy. They removed part of my colon and all of my rectum. My body image means the world to me, and this colostomy really messes with my mind at times. I was reading this article and was wondering if this would work for me. PLEASE HELP!

In April 2011, I had a cancereous tumor removed from the vagina, but a good portion of my anal/rectum muscles were removed also. I was referred to a colon rectal surgeon to have my colostomy bag taken down, but he could not because I have very litte to anal muscles. He said that I would have to find a surgeon who specializes in Artificial Anal Spinchter. Do I quality for thie surgery? If so, please let me know. I am really tired of this Bag. HELP!!

satisfactory informations/explanations..very cleared.I want most updated cases of this surgery..because my friend will be having operation of rectal cancer..he was told to have colostomy bag after surgery but i dont know which is safer and easier..artificial sphincter or colostomy..please help..i have only little idea about it..

A doctor did a supra pubic procedure on my bladder, however,most of the urine is draining through my penis and not to my urinary leg bag. Why is this? I have a suspicion that the catheter was not placed properly. The doctor used a 12 french catheter the first time, then after three weeks replaced it with 14,then 16, then 18, then 20, then 22. I am now on this large catheter but still most of the urine still drains to my penis. Is there a way to pull out the catheter, let it heal then start a new supra pubic procedure?

I am scheduled to get an artificial bladder sphincter by a new urologist (to me). Ten years ago, I had laser TURP for BPH that removed my sphincter along with the prostate tissue. Since then, I've had repeated collagen injections, biofeedback, and a sling inserted. What worries me is that the urologist has failed in repeated (and painful) attempts, to catheterize me for urodynamic testing. Since the laser TURP fiasco (continued incontinence, retrograde ejaculation, erectile dysfunction), I am afraid to go ahead with the artificial sphincter, particularly since I may need to be catheterized and he has been unsuccessful in repeated attempts. I am scared - what should I consider doing?

Had artificial spinster implanted 1 year ago. Still having pain at the bottom of the testicles and shooting pain up the abdemin.Is this normal and how long will it stay. They keep telling me it will get better.

I think these Doctors are playing games with us,I don`t think they realy feel what we feel when it come to waring THE BAG,so be creative keep serching somthing will come up for us one day,Don`t get me wrong their are great Doctors out here, and love what they do, but their are those out here that`s all about the dollar.They can replace a human heart,liver,kidney,they replaced a mans arm and they can not stop a grown man from shitting on himself !!!

My name is Roberto Ravazio.
I live in southern Brazil
I ostomy pouch 20 years, and can not stand anymore.
Never, never I had job and girlfriend and social life because of the stoma.
It is the realization of my life doing the implant surgery anal sphincter
I used the google translator to write this message because I can not speak English.
love to have contact with the drug class that has experience in this type of surgery: anal sphincter implantation.
thank you
10 October 2012 the 19 55 'time in Brazil'

I have had my anal sphincter removed with some of my lower bowel due to rectal cancer. I have a colostomy pouch. Will I ever be able to have a rectal sphincter implant performed? Is there any one I can discuss this with in New Zealand? 14th April 2014.

Hi. I have a daughter who is 15 yrs old who had rectum missing since her birth .she had a problem of common cloaca for which she was. Operated at the age of 2yrs .as now she growing the control of rectum is70% .I want to know is their any rectum surgery that could bring the control .or are artificial rectum available as I belong to india we don't have such facilities . I would be greatly thankful if u can tell me the place and the expert doctor working on this field.

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